Urethral Complications Post-Holmium Laser Enucleation of the Prostate: A Seven-Year Experience

Abstract

Background:

Urethral strictures (US) and bladder neck contracture (BNC) are troublesome complications of transurethral surgery. We aimed to report the incidence, risk factors, and management of US and BNC post-holmium laser enucleation of the prostate (HoLEP) together with review of literature.

Patients and Methods:

A retrospective review of prospectively managed HoLEP patients in one institution between 2015 and 2021 was performed. The study included patients with complete follow-up of at least 1-year. Multivariate regression analysis for risk factors of US or BNC was performed. Appropriate statistical analysis methods were used.

Results:

Out of total 1055 HoLEP patients, 566 patients were included. Eleven (1.94%), 8 (1.41%), and 1 (0.17%) patients developed US, BNC, and both, respectively, while 8 (1.41%) patients had postoperative recurrence of intraoperatively diagnosed US. With multivariate regression analysis, intraoperative US (p = 0.0055, odds ratio [OR] = 15.5, confidence interval [95% CI] = 2.2–37.7), intraoperative need for meatotomy (p = 0.0019, OR = 7.69, 95% CI = 2.12–27.8), and longer operative time (p = 0.0250, OR = 1.043, 95% CI = 1.005–1.083) were predictors of US/BNC. For US patients, urethral dilatation under local anesthesia was sufficient in 14 (70%) patients while 6 (30%) patients had visual urethrotomy. Patients with BNC were managed by endoscopic bladder neck incision.

Conclusion:

Although the US/BNC are annoying long-term sequalae that may complicate HoLEP, the incidence is still low and can be easily managed. Diagnosed intraoperative stricture, need for meatotomy, and longer operative time are the main predictors of urethral complications post-HoLEP.

Introduction

Urethral strictures (US) and bladder neck contracture (BNC) are unfortunate complications of transurethral prostate surgery. Transurethral surgery is considered the most common cause of iatrogenic US, accounting for about 41% of all causes. US occurs in 4.5% to 13% of patients posttransurethral prostate surgery. It is also reported that 0.3% to 9.7% of transurethral prostate surgery are complicated with BNC.^1

–4

Holmium laser enucleation of the prostate (HoLEP) has increasingly grown as a surgical alternative for management of benign prostatic hyperplasia and rivals the success of the traditional technique of electrocautery transurethral resection of the prostate (TURP). HoLEP has proved high efficacy regardless the prostate size with minimal risk of blood loss, minimal perioperative complications, short hospital stay, and high postoperative patient satisfaction rates.^5
–7 However, US and BNC are still disturbing long-term complications with HoLEP due to the still need for a relatively large resectoscope sheath size and potential long operative time with large volume prostate. Studies have reported the incidence of US accompanying HoLEP of 1.4% to 4.4%, whereas the incidence of BNC post-HoLEP is reported between 0.6% and 5.4%.^8

–11

The most common location for US posttransurethral surgery is the bulbo-membranous urethra, followed by the fossa navicularis and penile urethra. The pathogenesis of US in transurethral surgery is still unclear but supposed mechanisms include breach of mucosal integrity with repetitive “in and out” movement of the resectoscope, lack of adequate lubrication, or pressure ischemia with the endoscope to the fixed bulbo-membranous junction.^12,13 Incidence of US is also postulated to depend on multiple factors as size of adenoma, duration of the surgery, the diameter of the resectoscope, temperature of irrigation fluids, and postoperative infection.¹⁴

In this study, we aimed to report the incidence, morbidity, and management of US and BNC complications following HoLEP through the experience with >1000 patients and studying possible risk factors for such complications with review of related literature.

Materials and Methods

A retrospective chart review of a prospectively maintained database of patients who underwent HoLEP for bladder outlet obstruction within the duration between August 2015 and August 2021 at Baylor Scott and White Medical Center was performed. The study included patients with complete follow-up data for at least 1-year follow-up postsurgery. Preoperative, operative, and postoperative data were collected. The data regarding the incidence, characteristics of US, and management of the US and BNC patients were collected. Multivariate analysis of the risk factors in the group of patients with US or BNC was performed.

Operative procedure

All the procedures had been performed by one surgeon (M.M.E.T.). Almost 90% of the HoLEP procedures were performed with general anesthesia either with laryngeal mask or endotracheal tube. Initial Calibration of the urethra was routinely done using the sequential Von Braun's dilators up to 28F. In case of tight urethral meatus and fossa navicularis, Otis urethrotome was used to cut the fossa up to 28F. Storz™ laser resectoscope sheath of either 28F or 26F was often used.

At first, either 5 or 7 o'clock incisions were made deep to the level of the surgical capsule and continued distally to the Verumontanum. Enucleation is usually done in standard two lobe retrograde enucleation technique through as a combination of gentle mobilization with the tip of the resectoscope and cutting whenever necessary.

Holmium laser energy settings of 80 and 40 W at a power setting of 2 J and frequency of 40 and 20 Hz, respectively, are used through 550-micron laser fiber. Lumenis MOSES™ Pulse technology was adopted since November 2019 for most HoLEP procedures. Morcellation was performed for HoLEP using Piranha™ morcellator system (Richard Wolf GmbH, Knittlingen, Germany). Three-way 22F Foley catheter was always inserted after surgery for continuous bladder irrigation. Voiding trial was usually performed at postoperative day 1 after removing the urethral catheter.

Statistical analysis

Sample characteristics are described using descriptive statistics. Frequencies and percentages are used to describe categorical variables. Means and standard deviations (or medians and ranges where appropriate) are used to describe continuous variables. A chi-square test (or Fisher's exact test when low cell counts are present) is used to test for associations in bivariate comparisons. A two-sample t-test (or Wilcoxon rank-sum test when appropriate) is used to test for differences in continuous variables between patients in two groups (patients with vs without US/BNC). The significance level was set at a p-value <0.05. A logistic regression model is used to understand the relationship between patients with stricture and no stricture (each separately, yet, respectively) between multiple variables. All statistical analyses were performed using the commercially available SAS (Statistical Analysis Software) Version 9.4 (SAS Institute, Inc., Cary, NC).

Results

The data of total 1055 patients who had HoLEP in our institution during this duration were reviewed. The study included only 566 patients with complete follow-up data up to 1 year after HoLEP. The median follow-up duration was 20 months. Table 1 shows the baseline characteristics of the whole included cohort.

Table 1.

Baseline Characteristics of All Patients

Variable	Result (n = 566)
Age, years, median (IQR)	73 (67–78)
BMI, Kg/m², median (IQR)	28.5 (25.8–31.6)
Preop urine retention, n (%)	228 (40.2)
Preop indwelling catheter, n (%)	148 (26.1)
Preop CIC, n (%)	80 (14.1)
Hx of prostatitis, n (%)	43 (7.6)
Positive preop urine culture, n (%)	144 (25.4)
Preop IPSS, median (IQR)	21 (16–27)
Preop QOL, median (IQR)	5 (3–6)
Prostate size, g, median (IQR)	90 (57–122)
PSA, ng/mL, median (IQR)	3.8 (1.8–6.7)
DM, n (%)	171 (30.2)
Qmax, mL/s, median (IQR)	8.8 (6–12)
PVR, mL, median (IQR)	98 (37–253)

BMI = body mass index; CIC = clean intermittent catheterization; DM = diabetes mellitus; IPSS = international prostate symptom score; IQR = interquartile range; PSA = prostate specific antigen; PVR = postvoid residual; QOL = quality of life.

Total 28 (4.94%) patients had urethral complications. Nineteen (3.3%) and 8 (1.4%) patients suffered postoperative US and BNC, respectively, while 1 patient (0.17%) had both US and BNC complications. Among the 19 patients with US, 11 patients had de novo stricture, while 8 patients had intraoperatively diagnosed US.

Among the US patients, US was bulbar in nine (45%) patients, penile in six (30%) patients, at the fossa navicularis at three (15%) patients, and bulbo-membranous in two (10%) patients. Presentation and diagnosis were early at 6 weeks follow-up visit in 10 (50%) patients, between 6-week and 6-month follow-up in 6 (30%) patients and late presentation after 6 months in 4 (20%) patients. BNC was diagnosed before 6 months follow-up in six (66%) patients, while it was later than 6 months in three (34%) patients.

In comparing the group of patients with US/BNC with the noncomplicated patients, the complicated patients had statistically significant history of chronic prostatitis (p = 0.0383), worse preoperative quality of life (QOL) (p = 0.0302), higher percentage of use of 28F vs 26F sheath (p = 0.0152), higher rate of diagnosed intraoperative stricture (p < 0.0001), higher need for meatotomy (fossa navicularis urethrotomy) (p < 0.0001), and longer postoperative catheterization (p = 0.0032) ( Table 2).

Table 2.

Bivariate Analysis of Urethral Stricture Patients vs Noncomplicated Patients

Variable	No US/BNC (n = 538)	US/BNC (n = 28)	p
Age, years, median (IQR)	73 (67–78)	71 (64–76)	0.3331
BMI, Kg/m², Median (IQR)	28.5 (25.8–31.6)	28.54 (25.8–31.3)	0.9487
Preop indwelling catheter, n (%)	143 (26.5)	5 (18.5)	0.3526
Preop CIC, n (%)	78 (14.5)	2 (7.4)	0.1531
Hx of chronic prostatitis, n (%)	38 (7.6)	5 (17.8)	0.0383
Positive preop urine culture, n (%)	137 (28.6)	7 (28)	0.2430
Preop IPSS, median (IQR)	21 (16–26)	20 (17–30)	0.3745
Preop QOL, median (IQR)	5 (3–5)	5 (4–6)	0.0302
Preop Prostate volume, median (IQR)	90 (60–122)	73 (61–105)	0.224
DM, n (%)	163 (30.5)	8 (28.5)	0.8267
Operative time, minutes, median (IQR)	51 (34–71)	47.5 (27–65)	0.4090
Sheath size used, n (%)
28F	231 (42.9)	20 (71.4)	0.0152
26F	304 (56.5)	8 (28.5)
22F	3 (0.56)	0
Intraoperative stricture, n (%)	22 (4.11)	8 (28.5)	<0.0001
Urethrotomy for fossa navicularis, n (%)	101 (18.9)	16 (57.1)	<0.0001
Catheterization time, days, median (IQR)	1 (1–1)	1 (1–3.5)	0.0032
PCa pathology, n (%)	83 (15.4)	3 (10.7)	0.1881
Positive PO urine culture, n (%)	76 (14.12)	2 (7.14)	0.309

p values denoted in bold are statistically significant.

BNC = bladder neck contracture; PO = postoperative; US = urethral stricture.

Diagnosis of chronic prostatitis was done either with history of recurrent urinary tract infection and expressed prostate secretions analysis or postoperative pathology specimens showing chronic inflammatory picture. In multivariate regression analysis model for multiple risk factors, presence of intraoperative US (p = 0.0055, odds ratio [OR] = 15.5, confidence interval [95% CI] = 2.2–37.7), need for fossa navicularis urethrotomy (p = 0.0019, OR = 7.69, 95% CI = 2.12–27.8), and longer operative time, (p = 0.0250, OR = 1.043, 95% CI = 1.005–1.083) were the statistically significant predictors of US and BNC complications.

Among patients with US, urethral dilatation under local anesthesia with Van Buren dilators was initially performed in 17 (85%) patients. With median follow-up of duration of 11 months (range 6–30 months), dilatation was sufficient in 14 (70%) patients while 3 (15%) patients required direct internal endo-visual urethrotomy (DIVU) after failed dilatation. Other three (15%) patients had DIVU from the start. All of them had endoscopic bladder neck incision with satisfactory results.

Discussion

US is one of the most distressing complications following HoLEP and all transurethral surgeries. The incidence of US after HoLEP was reported in some studies at 1.4% to 4.4%, whereas the incidence of BNC post-HoLEP is reported between 0.6% and 5.4%.^{8
–10,15,16}

In their report of morbidity in initial series of 206 patients, Kuo et al¹⁵ first reported the US incidence following HoLEP as 2.4%, while the BNC incidence was 3.9%. Shah et al¹⁶ then reported the incidence of US and BNC at 4.3% and 0.28%, respectively, with higher rate of US with prostate size >100 g vs 100–60 g and <60 g (4.8%, 2.6%, 1.3%, respectively). Elkoushy et al have reported that longer operative time and longer catheterization time was significantly associated with incidence of US.⁸ Table 3 concludes US/BNC incidence and risk factors within the previous reports of HoLEP-related complications.

Table 3.

Summary of reported incidence of US/BNC and associated findings in previous studies

Study	Enucleation sheath size	US incidence	BNC incidence	Findings
Kuo et al¹⁵	28F	2.4%	3.9%	• US were all bulbar.• All US treated with single office dilatation sound.
Shah et al¹⁶	26F	4.3%	0.28%	• Three patient categories according to size (<60, 60–100, >100 g).• Higher incidence of stenotic complications in patients with prostate >100 g (4.8%)
Elkoushy et al⁸	26F	2.05%	1.14%	• Longer operative time and postoperative catheterization were associated with US.• BNC was associated with smaller glands (<54 cc)• Total HoLEP reoperation rate of 4.3%.
Ibrahim et al¹⁰	26F	1.4%	2%	• US was dilated under local anesthesia in 71% while and 29% required VIU.• BNC developed only in patients with a small adenoma (<55 g), 60% of the patients had history of regular TURP.• BNC was diagnosed within the first year and after 2 years of follow-up in 46% in 54% of patients.
Thai et al⁹	28F vs 26F	2.98%	1.59%	• 28F resectoscope sheath was associated with statistically insignificant higher rate of US/BNC compared to 26F one.

HoLEP = holmium laser enucleation of the prostate; TURP = transurethral resection of the prostate.

In our results, history of chronic prostatitis, worse preoperative QOL, use of 28F sheath, intraoperatively diagnosed US, need for fossa navicularis urethrotomy, and longer postoperative catheterization were significantly higher in patients with US/BNC. With multivariate analysis, intraoperative US, need for urethrotomy, longer operative time, and larger intraoperative specimen weight were the predictors of US/BNC complications.

Elkoushy et al⁸ and Ibrahim et al¹⁰ reported that BNC was associated with small prostate size (<55 g). In our results, BNC was seen in nine patients with median prostate volume of 48 g (range 40–200 g); five (56%) and four (44%) patients have prostate size <55 and >55 g, respectively. We did not adopt prophylactic bladder neck incision in small-size prostate patients as proposed in few literature.¹⁷ Thai et al reported 26F or 28F resectoscope sheath regarding the rate of US and BNC post-HoLEP showing that the rate was statistically comparable although 28F sheath was associated with insignificant higher rate of both US and BNC (3.53% vs 1.8%, 2.35% vs 0%, respectively).⁹ In contrast to their findings, the results of the current study showed statistically higher rate of usage of 28F sheath in patients with US/BNC.

On the contrary, the rate of US in traditional TURP is estimated in the range of 1.7% to11.7%. It is postulated in multiple reports that the bipolar TURP may be associated with higher rate of US compared to monopolar TURP; with 6.1% to 8.3% vs 1.9% to 4.2%, respectively. While studies have reported the rate of BNC, post-TURP was reported at range of 0.14% to 9.6%.^12,18

–21 To the best of our knowledge, no studies have compared the incidence of US/BNC in both techniques. Grechenkov et al in their TURP series have illustrated that a larger diameter of the endoscope, increased prostate volume, repeated urethral catheterization, and previous history of chronic prostatitis were associated with the risk of developing of urethra or bladder neck stricture post-TURP.²²

In our series, urethral dilatation under local anesthesia was sufficient in 70% of US patients while 30% of patients had DIVU. This is almost similar to the management reported by reported by Ibrahim et al.¹⁰ In all patients with BNC, laser bladder neck incision was required and showed satisfactory results, which are consistent with all the previous reports.^8
–10

Conclusion

Although the US/BNC are annoying long-term sequalae that may complicate HoLEP, the incidence is low, and the management is not sophisticated in most patients. Diagnosed intraoperative stricture, need for urethrotomy for tight fossa navicularis, and longer operative time are the main predictors of urethral complications post-HoLEP.

Informed Consent

Informed consent was waived by the IRB.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

The author M.E. is funded by a full scholarship from the Ministry of Higher Education of the Arab Republic of Egypt.

Abbreviations Used

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